STATE OF CALIFORNIA CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

HEALTH AND HUMAN SERVICES AGENCY COMMUNITY CARE LICENSING DIVISION

APPLICANT INFORMATION
This form must be completed by all applicants for a facility license, (i.e., all individuals, each partner in a partnership, or chief executive officer or
authorized representative in a corporation.) If more space is required, attach additional sheet. Type or print clearly.
IDENTIFYING INFORMATION
NAME SOCIAL SECURITY NUMBER
(VOLUNTARY FOR I.D. ONLY) * SEX (M/F) ARE YOU 18 YEARS OR OLDER?

TITLE DRIVER’S LICENSE NUMBER VALID PLACE OF BIRTH

■ Yes ■ No
ADDRESS
(AREA CODE) TELEPHONE NUMBER
( )
OTHER NAME(S) USED BY APPLICANT

EDUCATION
ighest completed grade:1 2 3 4 5 6 7 8 9 10 11 12
NAME AND LOCATION OF HIGH SCHOOL DATE COMPLETED GED DATE

NAME AND LOCATION OF COLLEGE COURSE STUDY YEARS COMPLETED DEGREE DATE COMPLETED

1 2 3 4

1 2 3 4
REFERENCES
PERSONAL: (PLEASE GIVE REFERENCES, INCLUDING PRESENT AND PAST EMPLOYERS, WITH KNOWLEDGE OF YOUR ADMINISTRATIVE ABILITY.)
NAME ADDRESS RELATIONSHIP TELEPHONE

1.

2.
FINANCIAL: (PLEASE GIVE REFERENCES WITH KNOWLEDGE OF FINANCIAL RESOURCES AND BUSINESS PRACTICES.)
NAME ADDRESS RELATIONSHIP TELEPHONE

1.

2.
PRIOR LICENSURE STATUS
A. HAVE YOU EVER BEEN A LICENSEE OR CO-LICENSEE OF A RESIDENTIAL CARE FACILITY FOR THE ELDERLY,
COMMUNITY CARE, CHILD CARE OR HEALTH FACILITY? ■ YES ■ NO IF YES,, COMPLETE C AND D BELOW.
B. HAVE YOU EVER HELD A BENEFICIAL OWNERSHIP OF 10% OR MORE IN A RESIDENTIAL CARE FACILITY FOR THE ELDERLY,
COMMUNITY CARE, CHILD CARE OR HEALTH FACILITY OR BEEN AN ADMINISTRATOR, GENERAL PARTNER, CORPORATE
OFFICER, OR DIRECTOR OF ANY SUCH FACILITY?
■ YES ■ NO IF YES, COMPLETE C AND D BELOW:
C. NAME AND ADDRESS OF FACILITY EFFECTIVE DATES OF LICENSURE FACILITY TYPE

_________________ TO __________________

D. WERE ANY DISCIPLINARY ACTIONS TAKEN?

■ YES ■ NO IF YES, PLEASE EXPLAIN:

BUSINESS EXPERIENCE
A. HAVE YOU OWNED OR OPERATED ANY BUSINESS? ■ YES ■ NO IF YES, COMPLETE THE FOLLOWING:

Type Number of Your Title Date Date Reason for End

Employees Started Ended

B. DO YOU HAVE A PROFESSIONAL LICENSE OR CERTIFICATE? ■ YES ■ NO IF YES, COMPLETE THE FOLLOWING:

Type Period Held Issuing Agency

C. ARE YOU A MEMBER OF ANY PROFESSIONAL/TECHNICAL ASSOCIATION? ■ YES ■ NO IF YES, COMPLETE THE FOLLOWING:

Association Name Address

LIC 215 (7/04) (PERSONAL)

 WORK EXPERIENCE. BEGIN WITH YOUR MOST RECENT WORK EXPERIENCE. LIST ALL EXPERIENCES AND PERIODS OF
UNEMPLOYMENT IN THE LAST SEVEN YEARS. INCLUDE WORK EXPERIENCE FROM MORE THAN SEVEN YEARS, IF NECESSARY.
Dates Name and Address of Employer Basic Duties Termination Reason
FROM

TO

FROM

TO

FROM

TO

FROM

TO

FROM

TO

PERSONAL INFORMATION
A. Do you have any physical, mental, or medical condition that could impair your ability to care for the type of resident/client for whom you have requested licensure?
■ YES ■ NO If yes, please explain:

I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS FORM ARE CORRECT TO THE BEST OF MY KNOWLEDGE.
SIGNATURE COUNTY WHERE SIGNED DATE

* Federal law (at Title 5 United States Code Section 552a Note) states that:
Any Federal, State, or local government agency which requests an individual to disclose his social security account number shall inform that individual whether
that disclosure is mandatory or voluntary, by what statutory or other authority such number is solicited, and what uses will be made of it.